This entry is our account of a study selected by Drug and Alcohol Findings as particularly relevant to improving outcomes from drug or alcohol interventions in the UK. Links to other documents. Hover over for notes. Click to highlight passage referred to. Unfold extra text

Concern over abstinence outcomes in Scotland's treatment services

A study of drug users starting treatment in Scotland
revealed low rates of abstinence
nearly three years later, findings which have been widely misinterpreted. The figures derived from the
Drug Outcome Research in Scotland study (DORIS).
Like NTORS in England, this sampled patients
entering different
types of treatments and observed their progress during and after normal treatment
delivery.

The study's most significant outcome report
to date documented the
progress 33 months later of 695 (all who could be reinterviewed) out of
1033 people who started treatment in 2001.1
Though using other drugs, most saw their main problem as heroin.
Abstinence was the sole drug use outcome reported, defined as totally avoiding
drugs except alcohol or tobacco over the preceding three months. DORIS excluded from this designation anyone prescribed legal substitutes such as
methadone.

On this criterion, overall just 8%2 of the sample were abstinent.
For patients who had started treatment at detoxification or counselling
services, it was 6%, for prison-based services, 5%, and for
residential rehabilitation 25%, significantly higher than the other
modalities.

No corresponding figure was presented for patients who started the study
in methadone maintenance. Instead a figure was given for patients who
had started methadone after their first DORIS
treatment, about 3% of whom were abstinent. Another 8% confined their
(non-alcohol, non-tobacco) drug use to prescribed methadone, meaning that 11%
were no longer using illegal drugs. For residential rehabilitation this figure was 33%.

Abstinence was associated with positive outcomes in terms of social
integration (education/employment and crime), self-perceived health and mental
health. For example, 39% of non-abstinent (ex)patients had committed acquisitive
crimes over the past 17 months compared to 9% who were abstinent, and 11%
and 2% respectively had attempted suicide or harmed themselves.

These associations were said
to underline "the benefits ... of
drug users having an extended period of abstinence", implying that abstinence
caused or enabled other improvements. Yet abstinence was measured over the past
three months, associated " benefits" over the past 17. To establish
causality, cause must be shown to come before effect. It seems equally
conceivable that other life changes enabled abstinence or that there was a
complex multi-way interaction. Also, an analysis based on drug use frequency or
severity might have
found similar improvements associated with less than total abstinence.

As DORIS researchers warned, potential caseload differences make it unsafe to
assume that the various treatment modalities caused the associated differences
in abstinence rates. Similar considerations led NTORS
to avoid using statistical tests to compare the performances of different
modalities because a level playing field in terms of caseload could not be
assured.3 Since so few patients enter residential
care in Scotland, and since selection procedures should ensure that this
expensive option is reserved for those who could benefit most, it seems likely
that they differ from the average methadone patient. Another complication is that in DORIS as in other studies, over the years
patients traversed several treatment modalities, complicating the
assessment of what led to the eventual outcomes.

Nevertheless the research has highlighted how few drug users enter
residential rehabilitation in Scotland and how few become abstinent from
illegal drugs after an episode in methadone maintenance, raising
questions over the balance of investment in treatment modalities. However, for
the reasons given above, it would be unsafe to reset the balance solely on the
basis of these findings. Internationally, research on residential rehabilitation is sparse, methodologically weak and ambiguous
about its benefits relative to less expensive treatment options, while that
favouring methadone is more extensive and more convincing.456
Evidence for the special benefits of residential care is mainly confined to multiply problematic and more severe cases.7

For similar reasons it would be unsafe to assume that the findings support
the diversion of methadone patients to services aimed at abstinence from illegal
drugs and legal substitutes. Compared to well run methadone services, such
services have been associated with an extremely high rate of
relapse and resultant deaths because the short spell of
abstinence has left patients unprotected by tolerance to opiate-type drugs
yet failed to create the circumstances in which they could do without them.8

Rather than or in addition to rebalancing there may be a case for reviewing
the resourcing of methadone treatment in Scotland and the services provided by
the clinics. English figures show that nearly three times as much is spent on an episode of residential care as on an episode of methadone treatment.9 From its inception social reintegration has been
a major benefit of effective methadone maintenance.10
In this and other respects, services vary widely. Among the critical factors are
adequate, flexible dosing,
procedures which minimise both drop-out and throw-out, sufficiently
comprehensive services able to draw on wider social resources, staff committed to the
welfare of patients and if indicated to indefinite maintenance, and good organisation.

In 2007 an official report on Scottish methadone services suspected that insufficient resources were devoted to rehabilitating patients, found patchy adherence to UK dosing guidelines, differing views on the desirability of long-term prescribing, and
widely differing policies on supervised consumption.11
Such differences are bound to affect patient retention and outcomes and the
possibilities for rehabilitation.

Thanks for their comments on this entry in draft to Neil McKeganey of the University of Glasgow, David Best of the University of Birmingham, Mike McCarron of the Scottish Alcohol and Drug Action Team Association, and the staff of Glasgow Addiction Services. They bear no responsibility for the text including the interpretations and any remaining errors.